ON YOUR MARKS, GET SET, GO!
A FLYING START TO PREVENT INJURIES IN ATHLETICS
– Written by Pascal Edouard, France, Juan Manuel Alonso, Qatar, Jenny Jacobsson, Sweden, Frédéric Depiesse, France, Pedro Branco, Portugal, and Toomas Timpka, Sweden
The practice of athletics can lead to an increased risk for injury, with short-, medium- or long term consequences at sporting, financial and social levels1. Prevention of athletic injuries therefore represents an important area for athletes and all stakeholders (coaches, managers, family, sponsors… and especially health and sport science professionals)1,2. This area of concern also represents one of the major issues of international (the International Association of Athletics Federations (IAAF), the European Athletics Association (EAA)) and national sports federations (such as the French Federation of Athletics (FFA), and the Swedish Athletics Association (SAA)). Van Mechelen et al3described a four-step methodological sequence (Figure 1) of evidence-based injury prevention. In this context, and following this four-step framework, we have described the state of the art on injury prevention in athletics, based on the experience of an international group of researchers and practitioners, illustrating the efforts made so far by the IAAF, the EAA, the FFA and the SAA for athletes’ health prevention and protection.
STEP 1: WHAT ARE THE RATES OF ATHLETIC INJURIES?
How to collect data on athletic injuries?
Epidemiological studies are needed to determine athletic injury rates. A clear reproducible and valid method is fundamental to allow the comparison of data between studies, and to allow for long-term monitoring. We list the five key points of injury surveillance methodology in Table 1.
To date, there is a consensual method for injury data collection during championships, developed by the IOC4, and introduced to athletics at the IAAF World Championships5-8and European Championships9-11. Only a few studies, using different methods, analysed data from an entire athletics season; this does not allow a true comparison of the data from competition periods2. Members of international and national athletics federations recently developed a consensus statement providing definitions and methodological guidelines on how to perform epidemiological studies in athletics12. This is to support the implementation of long-term prospective cohort studies of athletes over one or more seasons.
Injury rates during international athletics championships
A total of 1510 injuries were collected from 14 international championships from 2007 to 2014, corresponding to an incidence of 100 injuries for 1000 registered athletes13. Injury risk was 25% higher for male compared to female athletes (110.3 ± 6.8 vs. 88.5 ± 6.7 injuries per 1000 registered athletes, respectively)13. The main locations of injuries were thigh, leg, knee and foot, with a higher incidence of thigh and leg injuries in male athletes. The main type of injury was muscle strains, followed by skin lesions (abrasions and lacerations), and ligament and tendon injuries, with a higher risk in male athletes for muscle injuries, and in female athletes for stress fractures. The risk of injury varied between events, with a higher risk in combined events, marathon and long distance running13. The main injury for diagnostic imaging was hamstring muscle injury (about 17%)14. In the last four weeks of the 2013 World IAAF Championships, 30% of the athletes participating in this study were injured, including a third who decreased their training load and about 4% who were not able to practice8.
Injury rates during the entire athletic season
Between 61-76% of athletes had at least one injury during an entire athletic season15-17. The incidence was reported as 3.6-3.9 injuries per 1000 hours of athletics16,17.
The location and type of injury varied according to the events, with a high prevalence of achilles tendinopathy and “shin splints” in middle- and long-distances, ankle injuries and low back pain in throwers, and thigh and hamstring muscle injuries in sprinters and jumpers1,15,17.
The injury mode of onset was more sudden in explosive events and more gradual in endurance events16. Overuse was the most frequent cause of athletic injury (72-96%)16,17.
Conclusion on the injury rates in athletics
We now begin to understand the extent of the problem (Table 2), however, we need to collect more epidemiological injury data to extend this knowledge to all athletic populations and during the entire athletic season2.
STEP 2: WHAT ARE THE RISK FACTORS FOR ATHLETIC INJURIES?
Injury risk factors during athletics championships
Epidemiological studies during international athletics championships reported the following information about athletic injury risk factors:
Gender: male athletes had higher injury rates than females9,13;
Age: higher injury rates are reported in athletes over 30 years9;
Event type: injury rates varied according to events with higher injury rates in combined event, marathon, middle- and long-distances13;
Training volume: higher training volumes before previous championships was associated with higher injury rates during championships (based on a pilot study of 74 athletes)11;
Injury just before a championships: an injury in the four weeks before the championships is a risk factor for a new injury during the championships8.
Injury risk factors during the entire athletic season
During the entire athletic season, the results are less clear, although some trends emerged:
Previous injury: a previous injury seems to be a risk factor for another injury17,18;
Gender: the influence of sex/gender remains unclear – higher risk in male15-17or in female athletes19,20according to studies;
Age: lower prevalence of injuries among juniors (<20 years) and higher among older athletes15,16;
Training load: influence of training load (volume × intensity) was reported in one study17;
Coach: fewer injuries in athletes who trained with a coach compared to athletes training alone15;
Performance level: the influence of the performance level remains unclear – the injury incidence increased with increased level19, or decreased with increased level15, or no influence16;
Psychological: maladaptive coping practice of self-blame was found to be associated with increased risk of overuse injuries21.
Injury risk factors for the first injury: Hamstring muscle injuries
Higher hamstring muscle injury rates were reported:
at start of the season22;
in boys than in girls23;
in masters compared to young athletes23;
in 4 x 400 m compared to 4 x 100 m23;
in athletes who had a previous hamstring injury24;
if the isokinetic hamstring/quadriceps ratio at the start of the season is less than 60% at 180°/s22.
Conclusion on the risk factors of injuries in athletics
Although some factors are associated with higher injury rates, our knowledge of athletic injury risk factors remain limited. We need more well-designed studies with high standards of data collection and analyses; these should be in a variety of athletic populations, taking into account event differences and the large variety of potential risk factors.
STEP 3: WHAT MEASURES MIGHT BE RELEVANT TO ATHLETICS INJURY PREVENTION?
We present ideas on injury prevention measures in Table 3. The aim is to reduce injury risk and/or severity.
For example, the Medical Commission of the FFA developed a program on improving athletes’ physical condition, “Decathlon of injury prevention”. The aim was to prepare athletes better and to prevent the most common athletic injuries, however, we have no information on how effective this initiative was to reduce injury risk and/or severity. Hamstring muscle eccentric strengthening exercises dedicated to athletes have also been proposed25.
International and national federations implemented coach teaching programmes aimed at improving coaches’ knowledge and coaching skills of athlete technical movement and training.
The involvement of medical expertise in planning and delivering of athletic competitions, their influence on competition regulations and field officials’ health education, are all important measures to prevent injuries; it is often well organized for higher level events, but uncertain at lower levels.
Optimal care pathways and commu-nication/interactions between injured athlete stakeholders are important26. It is paramount to maintain medical confidentiality and a qualified physician should always coordinate clinical care.
A model for a national-level organization of athletic sports events was developed in collaboration with the SAA. The aim was to reduce/prevent overuse injuries, by addressing organizational hierarchy drag, introducing a safety surveillance system, and providing an open forum for safety issue discussion27.
We should continue to creatively seek and implement measures to prevent athletic injuries. We should base these on current and improved future knowledge of steps 1 and 2, through multidisciplinary brain-storming and/or systematic reviews of prevention measures from other sports.
STEP 4: WHAT MEASURES ARE VALIDATED FOR ATHLETIC INJURY PREVENTION?
In other sports, mainly football, injury prevention programs have been evaluated and their effectiveness reported for preventing injuries. A meta-analysis of exercise interventions28including 25 randomized controlled trials, reported an overall favourable impact, especially for muscle strengthening programmes, reducing injuries with a third and halving the rate of overuse injuries.
In football, the FIFA 11+ program, consisting of strengthening exercises, balance and coordination work dedicated to football, was developed and validated scientifically for preventing football injuries29. The Nordic hamstring exercise (eccentric exercises focused on hamstring) have been validated to reduce hamstring muscle injuries in football30.
There is to our knowledge no study validating a measure, a programme or an injury prevention strategy specific to athletics. This should be a priority for future athletics-specific injury prevention studies.
SUMMARY AND PRACTICAL IMPLICATIONS
Following the four-step framework for injury prevention3, we present the state of knowledge on athletic injury prevention, and the efforts by international and national athletics federations in this area. Scientific knowledge on injury prevention mostly relates to step 1 on injury rates; we need more high quality studies to expand and validate our current knowledge base. Our athletic injury risk factor knowledge base on the other hand is still limited, and continued efforts to improve this is paramount. Although various preventative measures have been proposed, none of these have been scientifically validated for its effectiveness in preventing athletics injuries. This should be a priority for future research on athletic injury prevention.
The authors want to thank the International Association of Athletics Federations (IAAF), the European Athletics (EAA), the French Athletics Federation (FFA), and the Swedish Athletics Association (SAA) for their help and support.
Pascal Edouard M.D., Ph.D.
Sports Medicine Physician
Assistant professor at the Sports Medicine Unit at the University-Hospital of Saint-Etienne, France
Member of the Inter-university Laboratory of Human Movement Biology (LIBM), University Jean Monnet
Saint Etienne, France
Member of the Medical Commission of the French athletics federation (FFA)
Juan-Manuel Alonso M.D., Ph.D.
Sports Medicine Physician
Sports Medicine Department Aspetar – Qatar Orthopaedics and Sports Medicine Hospital
Jenny Jacobsson P.T., Ph.D.
Assistant professor at the Athletics Research Center at Linköping University Linköping , Sweden
Member of the Medical Commission of the Swedish Athletics Federation
Frédéric Depiesse M.D., M.Sc., D.O.
Sports Medicine Physician
University Hospital of Martinique, France
Chair of the Medical Commission of the French athletics federation (FFA)
Member of the European Athletics Medical and Anti-Doping Commission
Member of the IAAF Health and Science Commission
Pedro Branco M.D.
Sports Medicine Physician
Chair of the European Athletics Medical and Anti-doping Commission
Member of the IAAF Health and Science Commission
Toomas Timpka M.D. Ph.D.
Professor of Social Medicine and associate professor of Medical Informatics at Linköping University, Sweden
Head of the Athletics Research Center at Linköping University
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